The Psychiatry of Physical Injury
Dr Tim Web
24 March 2015
The Psychiatry
of Physical Injury
Dr Tim Webb
Consultant in Adult Psychiatry
& Medico-legal Expert
Cambridge Medico-Legal Forum
Downing College, Cambridge: 24 March 2015
Quick CV
1987 to date: Consultant in Adult Psychiatry
Plymouth (3 years), West Suffolk (24 years, Care UK (1 year)
1989 to date: Medico-legal expert
2400+ reports to date
What I aim to do
1.
2.
3.
4.
5.
Give you an outline of mental disorder
Explain those commonly found in Claimants
Comment on how DSM-5 has affected things
Give some candid insights into treatment
Perhaps mention some common pitfalls
1. An outline of mental disorder
• Brain diseases – (e.g. dementia, delirium)
• Substance misuse – (intoxication, dependency, harmful
use, induced states)
• Gross neurodevelopmental – (learning disabilities,
autism)
• Subtle neurodevelopmental – (ADHD, personality
disorder)
• Psychosis – (schizophrenia et al)
• Mood – (depression, bipolar et al)
• Anxiety, psychosomatic & stress (formerly “neurosis”)
Dealing with mental disorder
• Psychiatrists and psychologists
• Children, working age adults and the old
• Other sub-specialities
• NHS priorities and real life
What NHS planners think of psychiatry
2. Common conditions in Claimants
• Trauma syndromes
• Depression and anxiety
• Psychosomatic pain and disability
• Brain injury – not for this talk
Post-Traumatic Stress Disorder
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PTSD definition in ICD-10: 600 words
PTSD definition in DSM-5: 9000 words
Definition creep: simple vs complex
80% overlap with other conditions
– Alcohol & substance abuse
– Depression
– (Brain injury, chronic pain & others)
• Still not based on any defined pathology
Depression and anxiety
• The first a disease
• The second a pan-psychological symptom
• Causation grossly misunderstood
• Impact grossly underestimated
• Treatment rates scandalously low
Types of psycho-somatic disorder
• Somatic Symptom Disorder (psychological distress
presenting with physical symptoms)
• Illness Anxiety Disorder (hypochondria)
• Conversion Disorder (now 100% neurological)
• Psychological Factors Affecting Other Medical
Conditions
• Factitious Disorder (Munchausens)
Somatisation case study: chronic pain
• Defining its presence (active tissue damage)
• Chronic pain syndromes (CNS facilitation)
• CFSME / fibromyalgia (somatoform conditions)
• Pre-index vulnerability (with / without history)
• Depressive amplification (?? CNS facilitation)
• Pain behaviours (fears, beliefs & routines)
… and it doesn’t stop there
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69% of severe pain have depression / anxiety
High rates of psycho-toxic medication
Antidepressants have multiple actions
Many mood stabilisers treat chronic pain
• … and that is the non-litigants
Treatability in theory
• Antidepressants
– Useful in most conditions
– Available via GP on the NHS
• CBT-based psychological interventions
– Broad application
– Available via IAPT teams on the NHS
• Mood stabilisers / pain modulators
– Useful in some conditions
• Specific psychological interventions
– Highly effective in some conditions
Treatability in practice
• Antidepressants
– GP skills and willingness highly variable
– NHS mental health not geared to this
• CBT-based psychological interventions
– NHS interventions cash-strapped and service-driven
– Tailored programmes in private sector only
• Mood stabilisers / pain modulators
– Beyond the scope of most GPs
• Specific psychological interventions
– Only available in the private sector
Information in letter of instruction
• DO NOT SEND info on how to write a report
• DO NOT SEND hard copy hospital records
• ALWAYS SEND other reports and GP records
• Tell me why you want them to be seen
• Tell me what aspects concern you
Common pitfalls
• Culture-bound theories of distress
– Underestimating the importance of physical illness
– Overestimating the impact of upset
• Forgetting to mention the head injury
• Not bothering to make the Claimant better
Thank you!!
Dr Tim Webb
MB ChB FRCPsych
www.mss-medicolegal.com